Oral Health Status and Treatment Needs of Iruligas at Ramanagara

Oral Health Status and Treatment Needs of Iruligas at Ramanagara District,
Karnataka, India
S Kadanakuppe1, PK Bhat2
ABSTRACT
Objectives: To assess the oral health status and treatment needs of Iruliga tribal community residing at
Ramanagara District, Karnataka, India.
Methods: The total population of 2605 Iruligas residing at 26 villages of Ramanagara District was included for the study. Data were collected using World Health Organization (WHO) 1997 ‘Oral Health
Assessment Form’. Examination was done under good natural light using a mouth mirror and community periodontal index (CPI) probe.
Results: The total study population was 2605, comprising 1545 males and 1060 females in the age group
of 1–80 years with the mean age of 30.56 ± 19.51. The majority of Iruligas (79.8%) used chew sticks as
an oral hygiene aid. Subjects with leukoplakia were found to be 3 (0.12). The most commonly seen enamel
opacity/hypoplasia was diffuse opacity affecting 930 (35.7%) subjects. A mild form of dental fluorosis affected 1658 (63.65%) subjects. Subjects with bleeding were only 4.22%; subjects with calculus were
57.9%; those with shallow pockets (4–5 mm) were 22.0% and subjects with deep pockets (≥ 6 mm) were
3.67%. The prevalence of dental caries among Iruligas was found to be 7.52%. The mean number of decayed, missing, filled (DMF) permanent teeth per person was 0.55 ± 0.1. Definite malocclusion, which
required elective treatment, was noted in 14.1%. Iruligas with need for referral were found to be 29.94%
(n = 780) according to the various treatment needs required for different oral diseases.
Conclusion: This study revealed less prevalence of oral diseases among Iruligas, highlighting the role of
good oral health practices prevalent among this isolated population.
Keywords: Aboriginal, oral health, tribe
Estado de la Salud Oral y Necesidades de Tratamiento de los Iruligas, en el Distrito
de Ramanagara, Karnataka, India
S Kadanakuppe1, PK Bhat2
RESUMEN
Objetivos: Evaluar el estado de salud oral y las necesidades de tratamiento en la comunidad tribal Iruliga, que reside en el Distrito de Ramanagara, Karnataka, India.
Métodos: La población total de 2605 Iruligas que residen en 26 aldeas del Distrito de Ramanagara, fue
incluida en el estudio. Los datos fueron recogidos usando el Formulario de evaluación de la salud oral
(OMS) de 1997. El examen se hizo bajo buena luz natural, usando un espejo bucal, y la sonda Índice Periodontal Comunitario (IPC).
Resultados: La población total del estudio fue 2605, y abarcó 1545 varones y 1060 hembras en el grupo
etario de 1–80 años, con una edad media de 30.56 ± 19.51. La mayoría de los Iruligas (79.8%) usaban
palillos de masticar como medio para la higiene oral. Se halló que los sujetos con leucoplasia oral eran
3 (0.12). La hipoplasia u opacidad del esmalte más común fue la opacidad difusa que afectaba a 930
(35.7%) sujetos. Una forma leve de fluorosis dental afectaba a 1658 (63.65%) de los sujetos. Los sujetos con sangramiento fueron sólo el 4.22%. Los sujetos con cálculo fueron el 57.9%; los que presentaban bolsas poco profundas (4–5 mm) fueron el 22.0% y los sujetos con bolsas profundas (≥ 6 mm) fueron
From: 1Department of Public Health Dentistry, VS Dental College and Hospital, Bangalore and 2Department of Preventive and Community Dentistry,
Raja Rajeshwari Dental College and Hospital, Bangalore, India.
West Indian Med J 2013; 62 (1): 73
Correspondence: Dr S Kadanakuppe, 1256 ‘Nesara’, 4th cross, Paduvana Road,
Kuvempunagar, Mysore, Karnataka 570023, India. E-mail: sushikadanakuppe
@gmail.com
74
Oral Health Status and Treatment Needs
el 3.67%. Se halló que la prevalencia de las caries dentales entre los Iruligas fue de 7.52%. El número
promedio de dientes permanentes con caries, faltantes y obturados (DMF) fue 0.55 ± 0.1. La maloclusión definida, que requirió tratamiento electivo, se hizo evidente en 14.1%. Se halló que los Iruligas con
necesidad de ser remitidos fue un 29.94% (n = 780) de acuerdo con las diferentes necesidades de tratamiento requeridas para las diferentes enfermedades orales.
Conclusión: Este estudio reveló menos prevalencia de enfermedades orales entre los Iruligas, destacando el papel de las buenas prácticas de la salud oral prevalentes entre esta población aislada.
Palabras claves: Aborigen, salud oral, tribu
West Indian Med J 2013; 62 (1): 74
INTRODUCTION
The aboriginal populations of India, unevenly distributed
throughout the subcontinent, are called ‘scheduled tribes’ in
the Constitution. They form a substantial indigenous minority
comprising 8.2% of the total Indian population as per census
2001. Many smaller tribal groups are quite sensitive to ecological degradation caused by modernization. The ‘Iruliga’
tribal community residing at Ramanagara District, Karnataka,
India, is the jungle tribe of the plains, some of them residing on
the lower elevations of the hills and in the forest of the plains.
A few folkloric research studies have been done on this tribe,
which describe the influence of modernization in the past two
decades, on their cultural and socio-economic life, but none on
their general or oral health status (1–2). It is important to assess and describe their oral health status in light of these
changes. Hence this pioneering study aims to assess the oral
health status and treatment needs of the ‘Iruliga’ community,
which is transitioning from a hunter-gatherer lifestyle to a more
modern lifestyle.
SUBJECT AND METHODS
Since the census report from The Directorate of Census Operation, Karnataka could not provide the population size of this
specific tribe, the census conducted on this tribe by a folkloric
study was considered (1). Accordingly, it was reported that
around 2500 Iruligas reside in Ramanagara, scattered in 26
different villages. Before the start of the study, preliminary
visits to the study area were made to ascertain the population
size by obtaining information from the village panchayats of
the concerned villages along with population enumeration by
housing census. The natives belonging to the Iruliga tribe residing at the villages of Ramanagara District who were willing
to participate were included. The study obtained approval
from the Institutional Review Board.
Data were collected using the World Health Organization (WHO) 1997 ‘Oral Health Assessment Form’ (3). Examination was done under good natural light using a mouth mirror
and community periodontal index (CPI) Probe. Boxes 29 and
30 of the WHO oral health assessment form were utilized to
collect information regarding oral hygiene practices and habits
and the details were collected by personal interview. Before
the start of the study, the examiner was standardized and cali-
brated according to guidelines given by WHO oral health surveys, basic methods (3). The intra-examiner reliability was
also assessed to ensure consistency (kappa value, ϰ= 0.86).
Repeated attempts were made to examine those people who
were not available at the first attempt of examination.
The source of drinking water was bore well. A sample
of drinking water was collected at each examination site (each
Iruliga colony in 26 villages) for analysis of fluoride levels.
Fluoride analysis was done using UV-spectrophotometry by
Zirconium (IV)-Alizarin Red S method.
Chi-square test was used and statistical significance for
the study was achieved when p < 0.05 with 95% confidence
level.
RESULTS
The total study population enumerated and assessed was 2605,
comprising 1545 males and 1060 females, age range 1–80
years with the mean age of 30.56 ± 19.51. The distribution of
the total population by occupation showed that 47 (1.80%)
practiced only hunting; 2443 (93.8%) worked as coolies as
well as carried out hunting occasionally and 115 (4.4%) practiced other occupations like lumbering from their forests.
The usage of oral hygiene aids showed that 2079
(79.8%) Iruligas used chew sticks, whereas 390 (14.9%) of
them used the finger with either rangoli powder/salt/charcoal.
Only five (0.19%) Iruligas used the finger with either toothpaste or toothpowder. Toothbrush, with either toothpaste or
toothpowder, was used by only one (0.03%) Iruliga.
Iruligas used alcohol occasionally [790 (30.32%)]; 281
(10.78%) used smokeless form of tobacco, 245 (9.4%) of them
smoked tobacco and 616 (23.64%) Iruligas chewed pan only
without tobacco.
Assessment of oral mucosal lesions showed that the
number and percentage of subjects with leukoplakia were
found to be 3 (0.12%), ulceration 2 (0.08%) and acute necrotizing gingivitis 6 (0.23%).
The most commonly seen enamel opacity/hypoplasia
was diffuse opacity, affecting 930 (35.7%) subjects, followed
by demarcated opacity and demarcated and diffuse opacity, affecting 884 (33.93%) and 299 (11.48%), respectively (Fig. 1).
The number and percentage of Iruligas with dental fluorosis,
by level of severity, indicated that 1658 (63.65%) subjects were
Kadanakuppe and Bhat
opacity
75
opacity
hypoplasia
hypoplasia
Fig. 2:
Fig. 1:
Prevalence of enamel opacities/hypoplasia among the Iruliga population.
affected with a mild form of dental fluorosis, followed by questionable, 262 (10.06%), very mild, 67 (2.57%) and moderate,
11 (0.42%).
The fluoride levels assessed in all 26 villages was in the
range of 1 ppm to 2.85 ppm. The dental fluorosis in all the
five villages with fluoride level less than 1.5 ppm compared
to that of other villages with fluoride levels above 1.5 ppm was
significantly less. Questionable, mild and very mild forms of
dental fluorosis were seen in 29.3%, 28.2% and 0.6% in below
optimum villages compared to 5.7%, 71.4% and 2.9%, respectively for the rest of the villages above optimum, which
were statistically significant (p < 0.001) [Table 1].
Table 1:
Dental
fluorosis
Table 2:
Mean number of sextants affected with periodontal disease
conditions.
CPI
Healthy
Bleeding
Calculus
Pocket (4–5 mm)
Pocket (6 mm or more)
Mean number of sextants excluded from examination
CPI: community periodontal index
Mean number
of sextants
0.14 ± 0.68
0.38 ± 1.11
3.87 ± 2.44
0.79 ± 1.50
0.06 ± 0.35
0.48 ± 0.79.
lus were 57.9% (3.87 ± 2.44), subjects with shallow pockets (45 mm) were 22.0% (0.79 ± 1.50), and subjects with deep pockets (≥ 6 mm) were 3.67% (0.06 ± 0.35). Tables 3 and 4 show
Association of fluoride levels in water samples at Iruliga settlements with the
prevalence of dental fluorosis
Normal
Questionable
Very mild
Mild
Moderate
Severe
Excluded
Not recorded
Total
Prevalence of periodontal disease conditions using community
periodontal index (CPI).
Fluoride levels#
Below optimumφ
n
141
137
3
132
0
0
21
34
468
%
30.1
29.3
0.6
28.2
–
–
4.6
7.2
100.0
Above optimumϕ
n
156
123
64
1526
11
2
112
138
2137
%
7.3
5.7
2.9
71.4
0.5
0.09
5.2
6.5
100.0
Fluoride levels in drinking water at Iruliga settlements.
Fluoride levels < 1.5 ppm
ϕ
Fluoride levels > 1.5 ppm
* Statistically significant
Combined
n
297
262
67
1658
11
2
133
172
2605
%
11.40
10.06
2.57
63.65
0.42
0.08
5.11
6.71
100.00
p-value
< 0.001*
< 0.001*
< 0.05*
< 0.001*
–
–
–
–
–
#
φ
Figure 2 and Table 2 show percentage and mean number
of sextants of Iruligas with periodontal disease conditions as
indicated by the community periodontal index. Subjects with
bleeding were only 4.22% (0.38 ± 1.11), subjects with calcu-
the percentage and mean number of sextants of Iruligas with
loss of attachment. Tables 5 and 6 show correlation of age with
prevalence of periodontal disease conditions and loss of attachment, respectively.
76
Table 3:
Oral Health Status and Treatment Needs
Prevalence of loss of attachment by gender
Loss of attachment
0–3 mm
4–5 mm
6–8 mm
9–11 mm
12 mm or more
Not recorded
Total
n
909
263
89
1
–
283
1545
Male
%
58.83
17.02
5.79
0.04
–
18.32
100.00
Table 5:
Female
n
%
585
311
12
–
–
152
1060
Combined
n
%
55.19
29.34
1.13
–
–
14.34
1494
574
101
1
–
435
100.00
2605
Mean number of sextants for loss of attachment
Loss of attachment
Mean number of sextants
0–3 mm
4–5 mm
6–8 mm
9–11 mm
12 mm or more
57.35
22.03
3.88
0.04
–
16.70
4.12 ± 2.44
0.79 ± 1.49
0.08 ± 0.47
0.001 ± 0.02
–
100.00
Correlation of age with the prevalence of periodontal disease conditions
Age
(years)
Persons
examined
(n)
<5
6–12
13–15
16–34
35–44
45– 64
65–74
≥ 75
–
172
227
747
555
381
180
23
Table 6:
Table 4:
Healthy
Bleeding
–
29
–
–
–
–
–
–
–
65
4
8
–
–
–
–
n
%
–
16.9
–
–
–
–
–
–
n
%
–
37.8
1.8
1.1
–
–
–
–
Calculus
n
–
78
223
640
400
169
–
–
%
–
45.3
98.2
85.7
72.1
44.4
0.0
0.0
Pocket
(4–5 mm)
n
%
–
–
–
59
128
199
166
21
–
–
–
7.9
23.1
52.2
78.2
91.3
Correlation of age with the prevalence of loss of attachment
Age
(years)
Persons
examined
(n)
<5
6–14
15
16–34
35–44
45– 64
65–74
≥ 75
–
–
76
747
555
381
180
23
0 – 3 mm
4 – 5 mm
6 – 8 mm
–
–
–
–
74 97.36
647 86.6
394 71.0
173 45.4
–
0.0
–
0.0
–
–
2
60
125
195
170
21
–
–
–
40
36
13
10
2
n
%
n
The prevalence of dental caries among Iruligas (Table 7)
was found to be 7.52% (n = 196). The mean number of decayed and missing permanent teeth per person was 0.82 ± 0.8
and 0.56 ± 1.2, respectively. The mean number of decayed and
missing deciduous teeth per person was 1.62 ± 0.2 and 0.98 ±
1.2, respectively. Filled teeth were not found among Iruligas.
The mean number of decayed, missing, filled (DMF) permanent teeth per person was 0.55 ± 0.1 and the percentage of
Iruligas with four or more DMF teeth was 3.84. The mean
number of DMF primary teeth per person was 0.98 ± 2.8 and
the percentage of subjects with four or more primary teeth was
4.54%.
The prevalence of root caries among Iruligas was found
in the age groups of 45–64, 65–74 and ≥ 75 years with 1.30%
%
–
–
2.63
8.0
22.5
51.2
94.4
91.3
n
Table 7:
%
–
–
–
5.35
6.49
3.41
5.56
8.70
Total
n
–
–
–
–
–
–
1
–
%
–
–
–
–
–
–
0.5
–
–
–
–
40
27
13
14
2
–
–
–
5.4
4.9
3.4
7.8
8.7
≥ 12 mm
n
–
–
–
–
–
–
–
–
%
–
–
–
–
–
–
–
–
Prevalence of dental caries by age
Age (years)
<5
6–12
13–15
16–34
35–44
45– 64
65–74
≥ 75
9 – 11 mm
Pocket
(6 mm or
more)
n
%
Persons examined
(n)
253
191
229
747
555
383
192
55
2605
Prevalence of caries
n
%
25
12
34
45
24
24
21
8
196
9.88
6.28
14.8
6.02
4.32
6.26
10.93
14.54
7.52
Kadanakuppe and Bhat
(n = 5), 5.20% (n = 10), and 14.54% (n = 8), respectively. The
mean number of teeth per person with root caries in the same
age groups was found to be 0.01 ± 0.7, 0.05 ± 1.1 and 0.14 ±
0.23, respectively. It was found that 6.26% (n = 24), 10.93%
(n = 21), and 14.54% (n = 8) of Iruligas in the age groups of
45–64, 65–74, and ≥ 75 years, respectively had coronal and/or
root caries. The mean number of teeth per person with coronal and/root caries in the same age groups were 0.06 ± 1.1,
0.10 ± 0.6, and 0.14 ± 0.23, respectively. Treatment needs
among Iruligas as shown in Fig. 3 indicates that only 8.86%
Table 9:
77
Prevalence of dentofacial anomalies among Iruliga population
Dentofacial anomalies
Missing incisor, canine, premolar teeth
Crowding in incisal segment
Spacing in the incisal segment
Diastema
Largest anterior maxillary irregularity
Largest anterior mandibular irregularity
Anterior maxillary overjet
Anterior mandibular overjet
Vertical anterior open bite
Anteroposterior molar relation
Number
(n = 1913)
27
794
410
415
149
740
1840
6
3
45
%
1.4
41.5
21.4
21.6
7.8
38.7
96.2
0.3
0.16
2.4
Iruliga population is classified based on the standard disease
activity index (DAI) scores. Accordingly, 71.4% of Iruligas
have no abnormality or minor malocclusion, and only 2.8% of
Iruligas had very severe or handicapping malocclusion, in
whom treatment is mandatory (Fig. 4).
Fig. 3:
Percentage distribution of treatment needs.
(mean number of teeth = 0.61 ± 1.2) needed surface fillings
and 3.22% (mean number of teeth = 0.34 ± 0.9) needed extraction of teeth.
Number and percentage of Iruligas with prosthesis, by
type of prosthesis and by jaw show that only 2 (0.08%) subjects had partial denture in the upper jaw. Table 8 shows numTable 8:
Percentage of subjects with prosthetic need
Prosthetic need
No prostheses needed
Need for one unit prosthesis
Need for multi-unit prosthesis
Need for combination of one and/or
multi-unit prosthesis
Need for full prosthesis
Not recorded
Total
Upper
n
2412
31
12
9
96
45
2605
%
92.6
1.2
0.5
0.3
3.7
1.7
100.0
Lower
n
2418
25
2
44
71
45
2605
%
92.8
0.9
0.8
1.7
2.7
1.7
100.0
ber and percentage of Iruligas requiring prosthesis, by type of
prosthesis and by jaw. Only 96 (3.7%) and 71 (2.7%) Iruligas
needed full prosthesis in the upper and the lower jaw, respectively.
Table 9 shows the prevalence of dentofacial anomalies
among Iruligas. The severity of malocclusion within the
Fig. 4:
Prevalence of dentofacial anomalies among Iruliga population by
level of severity and treatment indication.
Iruligas with need for referral were found to be 29.94%
(n = 780) according to the various treatment needs required for
different oral diseases.
DISCUSSION
The influence of modernization on the Iruliga population
within the last two decades has slowly forced them from their
traditional hunter-gatherer lifestyle to adopt a non-tribal
lifestyle (1). Both commercial forestry and intensive agriculture have proved destructive to the Handi-Gundi forests that
had endured Iruligas for many centuries. Some of them are
still hunters and gatherers who live in isolation in the HandiGundi hills and forests of Ramanagara. The phase of transition
from hunter-gatherer lifestyle to non-tribal lifestyle of Iruliga
aborigines is comparable with Tiwi aboriginals of Australia
78
Oral Health Status and Treatment Needs
(4), American Indian, and Alaska aboriginals (5) even though
Iruliga aboriginals have very recently made their way into
modernization.
The persistent nature of Iruligas to retain their traditional
lifestyle contributes to many of the indigenous health practices,
including oral health practices, seen in them. Iruligas (79.8%)
use chew sticks made of the twig of the Neem tree (Azadirachta indica, which they call “bevun kaddi”) to clean their
mouth. The Iruliga folk medicinal practice regards the use of
chew sticks to clean the mouth as a good daily practice.
Concerning the prevalence of leukoplakia (0.12%), the
present study revealed a relatively low prevalence in comparison with the findings of the study conducted by Ikeda et al on
Cambodian native people (1.1%) in which it was reported to be
significantly associated with smoking (6). Although alcohol
use is seen occasionally in Iruligas, they dislike tobacco use
due to the bad odour associated with smoking. This relatively
low prevalence of tobacco use (20.18% both smoke and
smokeless form) among Iruligas could be the factor for less
prevalence of oral mucosal lesions. Nonetheless, it clearly depicts the ill effects of tobacco usage.
The prevalence of enamel opacity/hypoplasia was
49.44% in this study, which is low when compared to the 99%
reported in the study conducted by Pascoe and Seow of the
Tiwi tribes and 98% reported in a study conducted by Seow et
al on aborigines of Brisbane, Australia (4, 7). By condition, the
prevalence of diffuse opacity was 35.7% (n = 930), followed
by demarcated opacity (33.93%, n = 884), both demarcated
and diffuse opacity (11.48%, n = 299), and hypoplasia (0.73%,
n = 19). These findings are low when compared to the prevalence of enamel opacities and hypoplasia of 78% and 85%, respectively reported by Pascoe and Seow (4). The authors
attributed the high prevalence of enamel hypoplasia to the extremely poor general health, which was likely to lead to derangements of enamel formation. The reason for enamel
hypoplasia recorded in Iruligas could be due to other possible
causes of enamel defects, in addition to factors regarding general health, such as endemic fluorosis as the fluoride analysis
of drinking water of the study area revealed fluoride levels between 1.0 and 2.85 ppm.
Drinking water fluoride estimation depicts its correlation with dental fluorosis by level of severity. Five villages of
Iruliga settlement had water fluoride level below the cut off
point of 1.5 ppm as given by WHO (8). In all those five villages, most of the Iruligas were not found to be affected with
fluorosis even though a small portion of them were observed
with questionable form of fluorosis. This could be explained
by the fact that Iruligas keep migrating from one settlement to
the other due to their basic nomadic nature and mainly in
search of better occupation in plantations.
Iruligas suffer from various forms of periodontal disease
as depicted in Fig. 2, comparable to the findings of the study
conducted by Fareed (91.61%) on Soligas in Biligiri Ranga
Hills, India and to that of Peterson (91%) on Malagasy tribes
in Madagascar (9, 10). This finding is similar to the study con-
ducted by Mosha et al for the native Tanzanian population
(mean number of sextants = 3.3) and high compared to the
findings of the study conducted by Skrepcinski and Niendorff
on American Indians and Alaska Natives [mean number of sextants = 1.8] (11–12). Both studies indicated that calculus was
the most commonly found condition in all age groups.
The prevalence of pockets was found in those 34 years
and above. The prevalence of periodontal pockets (CPI score
3 and 4) among Iruligas was found to be 26.67% which does
not agree with the findings of 60.8% (CPI score 3 and 4) of
Australian aborigines in Western Australia by Smith et al (13).
In the age group of 35–44 years, the prevalence of shallow
pockets (4–5 mm) in American Indians and Alaska Natives,
reported in a study conducted by Phipps et al, was 53.5% (14)
and those reported by Skrepcinski and Niendorff was 38.1%
[mean number of sextants = 1.7] (12) which was higher when
compared to Iruligas (23.1%; mean number of sextants = 0.79
± 1.50) in the similar age groups. But this was reversed in the
age group of 65–74 years as the prevalence of shallow pockets in American Indians and Alaska Natives (30.8%) is much
lower than that of Iruligas (78.2%). This decrease in prevalence with age in American Indians and Alaska Natives was
explained by the fact that areas with the lowest rates of pocketing were among those that also have the most missing teeth,
whereas higher prevalence in the 35–44 -year age group is explained by the fact that more teeth have been saved among children and adults by the IHS programme. Periodontal disease
will increase as more teeth remain in the mouth longer.
The prevalence of dental caries among Iruligas was
found to be 7.52% (n = 196). The mean DMF of Iruligas was
0.55, whereas the percentage of Iruligas with four or more
DMF teeth was 3.84%. These findings are comparable to those
of the study conducted by Mosha et al, which reports that
Tanga natives had 1.6% and Mbeya natives had 7.27% of
caries prevalence (11). Whereas it is low when compared with
a study conducted by William et al in which the mean DMFT
for Native Americans was reported to be 9.6 (15). The Iruliga
children below five years of age had 9.88% of caries prevalence (mean DMFT = 0.98 ± 2.8) which was very low when
compared with those of the studies conducted by Seow et al for
Aboriginal pre-school children of Australia (78%), Malagasy
aboriginal five-year old children of Madagascar reported by
Peterson (85%) and that reported by Endean et al on Anangu
aboriginal children of the same age group in the Anangu Pitjantjatjaraku lands in South Australia [mean 3.20] (7, 10, 16).
Native American children in the same age group showed caries
prevalence with regional differences ranging from 6% in
Aberdeen natives to 30% in Navajo native children (15).
Alaskan native children (< 5 years) had mean DMFT of 4.88
as reported by Jones et al when compared to 0.98 of Iruliga
children below five years of age (17). When compared to 88%
and 85% prevalence of dental caries of Wallisians and Melanesian 12-year old native children as reported by Bouregeois et
al (18), Iruliga children in the similar age group had lesser
prevalence (14.8%). Filled teeth were not found among Iruli-
Kadanakuppe and Bhat
gas. The mean number of DMF permanent teeth per person in
Iruligas was 0.55, which was less compared to 1.99 among
Mbeya natives and 2.38 of Tanga natives and much less when
compared to 9.66 among Native Americans (11, 15).
This study indicates the prevalence of caries in children
more than in adult Iruligas. The low prevalence rate of dental
caries among Iruligas could be explained by several factors.
The diet mainly constitutes Ragi and green leaves regularly
mixed in form since they hunt small animals like rats, which
they eat regularly (1). This diet is not a rich source of carbohydrates. Mainly school-going children of Iruligas have an
opportunity to mingle with non-tribal children and outside society and hence have a greater chance of exposure to refined
carbohydrates. Between meals, snacking is rarely seen among
Iruligas; if present, it is seen in Iruliga children who adapt more
rapidly to modernization. The Iruliga population is in the transitional stage, which exposes them, more so the children, to
modern civilization and with that the ravages caused by caries.
Even though the prevalence rate is less, the increased caries
prevalence among Iruliga children indicates the onset of the
effects of modernization on oral health. Another important factor to consider is the drinking water source, which was found
to be fluoridated (fluoride levels ranged from 1.00–2.85 ppm).
The beneficial effects of Neem chew sticks used by the majority of Iruligas should not be overlooked. In a dental health
survey in Sudan, Emsile reported for the first time fewer caries
in people using chewing sticks than those using toothbrushes
(19). Low caries prevalence among chew stick users has been
reported despite intake of a carbohydrate-rich diet and lack of
modern dental prophylactic measures (20, 21). In general, the
Namibian “muthala” users had a relatively low caries rate (22).
In a comprehensive survey of several thousands of school children in Zimbabwe, Sathananthan et al demonstrated that children who used chew sticks for oral hygiene had fewer carious
lesions than children who brushed their teeth with a conventional toothbrush and paste (23). An earlier controlled clinical study by Baghdady and Ghose reported that Sudanese
schoolchildren showed lower caries prevalence due to using a
miswak, and their diet (24). Similar results were noted in
Saudi children aged 13 to 15 years when compared with children in Western countries (25). Again, the main preventive factor reported was miswak use by these children. Hence, it is
important to realize its benefits, and in this direction, further research is needed to identify the role of Neem chew stick used
by Iruligas in reducing caries.
The treatment needs of Iruligas were low when compared to those of Native Americans (surface fillings = 1.72
mean number of teeth per person, 0.76 for crowns, and 0.63
for extraction), Alaska native, Tanga and Mbeya native people
[caries arrest = 1.13%, surface fillings = 16.3%, extractions =
24.6%] (11, 26). The lower treatment needs among Iruligas is
due to the lower prevalence of oral diseases.
The prosthetic status of Iruligas indicated that only two
(0.08%) subjects had partial denture in the upper jaw. These
findings, when compared to the findings of a study conducted
79
by Phipps et al (36.5% needed one unit and 40.0% multi-unit
prosthesis) are indicative of low prosthetic needs among
Iruligas (14). Iruligas who needed full prosthesis in the upper
and the lower jaw were also less (n = 167, 6.4%) when compared to Native Americans (55.3%).
Iruligas with 0.4% severe malocclusion required treatment considered highly desirable. Also noted was that 2.8% of
Iruligas had handicapping or very severe malocclusion which
required mandatory treatment. Genetic factors might have an
influence on the characteristics of malocclusion, which should
be given consideration when comparing the findings of this
study on Iruligas with other aboriginal groups.
About 29.94% of Iruligas were found to have referral
needs according to the various treatment needs required for
different oral diseases. Even though the percentage of people
with prosthetic needs are less among Iruligas which could be
due to their moderately good oral health, those who need prosthetic care are not aware of or not able to seek dental services.
Most of the Iruliga settlements near villages are remote, and
some with no access by road. Also, there are significant distances between villages. Most of the transportation is by public transport, which is not available to all villages. Hence
considerable distance has to be covered by walking through
Handi-Gundi hills and forest areas. This, coupled with cost of
travelling, makes Iruligas reluctant to seek dental care. The
primary health centres are the only sources of health services
for these people which are usually situated far away from their
settlements. Apart from these noted physical barriers, the cultural barriers to access oral care should be further evaluated in
this population in future studies.
This study revealed less prevalence of oral diseases
among Iruligas, but depicts the beginning of effects of modernization on oral health. The study also highlights the role of
good oral health practices prevalent among this isolated
population. Providing access to appropriate oral healthcare to
the underserved segments of the population is a complex problem. It is imperative that the specific barriers to care for
Iruliga population are identified and understood.
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